Remote Claims Auditor

SCAN Group; United States; Remote; USD 35,000 - 51,000; Full time

Benefits offered by this job

Annual bonus program

Wellness program

Generous PTO

11 holidays + floating + birthday

401(k) with employer match

Job summary

SCAN Health Plan is seeking a Claims Auditor for a remote role to perform pre- and post-pay audits, ensuring accurate payments and denials while upholding CMS requirements and internal policies. The role emphasizes collaboration across the Claims Department and adherence to federal guidelines.

The ideal candidate has 3+ years of complex claims processing or auditing experience in health plans, with knowledge of Medicare/Medicaid, DOFR/ COB, and systems like IKA and QNXT.

Qualifications

• 3+ years complex claims processing and/or auditing experience with a health plan, healthcare, or managed care organization.
• Proficient in processing/auditing claims for Medicare and Medicaid plans.
• Strong knowledge of CMS requirements regarding claims processing.
• Working knowledge of DOFR (Division of Financial Responsibility), COB (Coordination of Benefits).
• Current experience in both Institutional and Professional claim payment.
• Knowledge of health care benefit structures and insurance procedures in a Managed Care environment.

Responsibilities

• Conduct pre-pay and post-pay audits to ensure accurate claims payments and denials.
• Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards.
• Work assigned cases through SCAN's workflow system and apply correct status attributes to track issues.
• Notate cases/audits with required detail to ensure clarity of status and final resolutions.
• Collaborate with other units within the Claims Department to correct processing errors prior to final payment.
• Follow policies to maintain efficient and compliant operations and suggest improvements to management.

Skills

Claims auditing

CMS requirements

DOFR/ COB

Medicare/Medicaid

IQA/QNXT experience

Education

Associate's degree preferred or equivalent experience

Tools

IKA

QNXT

Job description

SCAN Health Plan is seeking a Claims Auditor for a remote role to perform pre- and post-pay audits, ensuring accurate payments and denials while upholding CMS requirements and internal policies. The role emphasizes collaboration across the Claims Department and adherence to federal guidelines.

The ideal candidate has 3+ years of complex claims processing or auditing experience in health plans, with knowledge of Medicare/Medicaid, DOFR/ COB, and systems like IKA and QNXT.